Illinois Workers' Compensation Commission Petition For An Immediate Hearing Under Section 19(B) Of The Act Form

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ILLINOIS WORKERS’ COMPENSATION COMMISSION
PETITION FOR AN IMMEDIATE HEARING
UNDER SECTION 19(b) OF THE ACT
Complete both sides of this form.
_______________________________________________
Case #
WC
________
____________________
Employee/Petitioner
v.
_______________________________________________
Employer/Respondent
I, the petitioner, request an immediate hearing in this matter. I am unable to return to work at this time because of the injuries or
disability caused by my employment, and I am not receiving temporary total disability benefits or medical benefits. I further
provide the following information:
1.
Date, time, and location of
accident
__________________________
_________________________
_________________
Date
Time
Location
2.
Description of accident
_______________________________________________________________________
3.
Nature of injury
_______________________________________________________________________
4.
Notice of the accident was given orally ___ in writing ___ to ________________________ on
.
___________________
5.
The employer has refused to pay proper compensation ___
medical benefits ___ .
6.
I did ___
did not ___ receive medical treatment for the accident from a medical provider selected by the employer.
7.
Name and address of medical
provider(s), and dates of treatments:
__________________________________________________________________
__________________________________________________________________________________________________
8.
Are any medical bills in dispute? If so, please list. _________________________________________________________
__________________________________________________________________________________________________
9.
On
I gave the employer (list name and job title) ________________________________________
____________________ ,
the following information stating I am unable to return to work: A recent statement, signed by a medical provider ____
Other (explain) ____________________________________________________________________________________
10. When was the last payment of temporary total disability benefits, if any? ______________________________________
11. In an attempt to resolve the disputed matters, _____________________________________________________________
Petitioner or petitioner's attorney (please print)
conferred with _____________________________________________________ by telephone ___
in person ___
Respondent or respondent's representative
on
but they were unable to resolve this dispute.
_________________________ ,
____________________________________________________
____________________________
_____________________________
Signature of petitioner or petitioner's attorney
Date
Telephone number
A
, R
. According to Commission Rules, you must file a Response to the Petition for an Immediate
TTENTION
ESPONDENT
Hearing within 15 days from the date this petition was served on you. If you fail to respond in good faith, attorney's fees or
penalties may be levied against you.
IC7 12/04 100 W. Randolph Street #8-200 Chicago, IL 60601 312/814-6611
Toll-free 866/352-3033
Web site:
Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084

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